Failure to Provide Nursing Coverage Results in Missed Medications and Resident Distress
Penalty
Summary
The facility failed to provide adequate nursing coverage for approximately four hours on two nursing units, affecting 53 residents, after one of two on-duty nurses left the facility unexpectedly during the night shift. This left only one nurse in the building, who did not assume responsibility for the other units, did not access the medication cart, and did not call for additional help. As a result, residents did not receive their scheduled or as-needed medications, and there was no licensed nurse in charge on each shift as required. One resident with chronic pain and a history of incomplete paraplegia, renal insufficiency, and chronic pain did not receive her scheduled pain medications, resulting in severe pain. She repeatedly requested her medications, but staff informed her that the nurse had left and no one could access the medication cart. The resident's pain became so severe that she called 911 for assistance. Emergency responders found her in visible distress, crying and screaming in pain, and confirmed that her medications had not been administered for several hours past the scheduled time. Another resident with a documented history of multiple anaphylactic reactions and systemic mastocytosis reported symptoms of an allergic reaction, including itching and facial swelling. She initially received Benadryl from the nurse before the nurse left, but when her symptoms worsened, she was unable to get further assessment or intervention from nursing staff. The resident ultimately self-administered her own epi pen, which she kept in her room, as no nurse responded to her call for help. A third resident also did not receive scheduled pain medication during this period. Staff interviews confirmed that there was confusion among staff regarding who was in charge, and no one took responsibility for the residents' care or medication administration after the nurse left.